Patient care in the time of coronavirus

Imagine it’s a sunny day in July 2020, and you’re arriving at the Boston University Henry M. Goldman School of Dental Medicine (GSDM) at 635 Albany Street for a dental procedure. You’ve already been screened for symptoms of COVID-19 over the phone twice—once 48 hours before your appointment, and once this morning.

When you arrive exactly 20 minutes before your scheduled appointment, you are screened once more, at a small white tent on East Newton Street. After filling out a survey questionnaire and having your temperature taken, you are cleared to enter the building.

As the automatic doors swoosh close behind you, you’re greeted by a patient coordinator, who checks you in from behind a sheet of plexiglass. Signs on the wall indicate in which direction to walk, and stickers on the floor encourage six feet of distance between you and other patients.

After a quick elevator ride – limited to two individuals at a time, which is monitored by an elevator manager – you arrive at your designated Patient Treatment Center, where you’re greeted by a staff member. They relay your arrival to a dental assistant, who guides you to a patient treatment chair. Finally, your provider arrives dressed in a bonnet, booties, a disposable gown, full face shield, eye protection, gloves and a N95 respirator, all of which they donned at a special station.

It’s a far different scene than the GSDM of the past, but in the time of COVID-19, it’s the new normal.

“A Dental Band-Aid”

On March 18, 2020, as COVID-19 started to spread in Massachusetts, GSDM ceased all in-person patient care to comply with a state order.

So, providers pivoted to teledentistry.

“A lot of [treatment] was done via the old-fashioned way,” Dr. Margaret Errante, associate dean for quality management, compliance and continuing education, and director of the Dental Health Center at 930 Commonwealth Avenue, said. “When a patient called in we would triage the patient and then a doctor would talk to them and try to figure out what the problem was, and how it could be remedied it with a Band-Aid—so to speak, a Dental Band-Aid—until they could be seen.”

Emergencies were diverted through to the oral surgery service at Boston Medical Center. So with a system to handle patients in place, the question became—when it became safe to resume in-person patient care, what would it look like? And how could GSDM do it?

Making a Plan

On April 23, 2020, Dean Jeffrey W. Hutter announced the creation of the Task Force for a Successful GSDM Academic Year 2020-2021 t, to be co-chaired by Errante and Dr. Alex Bendayan PROS 05, associate dean for digital development, technology and innovation and ad interim chair, Department of Restorative Sciences & Biomaterials. The task force was charged with developing a comprehensive plan for the 2020-2021 Academic Year at the Henry M. Goldman School of Dental Medicine (GSDM) in response to the effects of COVID-19 on normal operations. Comprised of eight working groups, the objective of the clinical working group, chaired by Dr. John Guarente, associate dean for clinical affairs, was to determine and implement the necessary parameters for patient care and clinical education of students/residents for academic year 2020-2021 in the GSDM Patient Treatment Centers (predoctoral, postdoctoral, and dental health centers) and Simulation Learning Center adhering to federal, state, and local directives and recommendations.

“Obviously For the patient treatment centers, the first area of concern is taking care of our patients,” said Errante. “But then if you think about the timing of things, it’s right before graduation for our students and residents. So some of our students and residents needed certain dental procedures to graduate.”

The school’s patient treatment centers posed some of the most significant challenges. In order for the patient treatment centers to re-open, the school needed approval from the state and the University.

“We really had to think from start to finish—when a person walks in until they leave, what is that process going to be?” Errante said. “And [that] has to be for the students, for the residents, for visitors, for faculty, for staff, and for patients.”

Bendayan emphasized the importance of creating a plan that prioritized the health and safety of every member of the GSDM community.

“I want to feel— entering that building, that I’m safe,” Bendayan said. “And if I feel safe, I know everyone will feel safe. And so that was our core. Our patients and our community, are we going to keep them safe, to the best available information, knowledge, and scientific evidence that we have?”

Working with the clinical working group and other working groups of the task force, Errante and Bendayan prepared a detailed plan for re-opening the Patient Treatment Centers at 635 Albany Street and the BU Dental Health Center at 630 Commonwealth Avenue, entitled, GSDM Resumption to In-Person Clinical Care due to COVID 19, which rounded out at 64 pages and demonstrated that GSDM could safely resume in-person clinical care.

“I am very grateful to all of the hard work that the Task Force put in to helping GSDM re-open safely,” said Dean Jeffrey W. Hutter. “Re-opening was certainly a complicated process, but they rose to the challenge and ensured that the school and patient treatment centers’ re-opening was as smooth and safe as possible.”

Unique challenges

The school faced a multitude of challenges when it came to its resumption of in-person clinical care, including developing plans that addressed the many functions – administrative, clinical, research, academic – the school serves, and the sheer size of its patient base.

At full capacity, GSDM averages about 600 appointments a day, which puts it in a higher risk pool than a smaller dental practice, according to Dr. John Guarente DMD 89, associate dean for clinical affairs.

“Because of our high risk, we have a higher reporting status to the Department of Public Health as compared to Dr. Dentist on the corner of Broadway and Park Ave,” he said.

Even as plans began to take shape to mitigate that risk and create a safe environment for patients, students, faculty, and staff, new information was being released daily, requiring task force members to update their approach continuously.

“Everything was a moving target,” Errante said. “Every day, something was changing, whether it was federal law, state law, Centers for Disease Control (CDC), Massachusetts Dental Society, and all the different players that came into place.”

There were a significant number of details that went into GSDM resuming in-person patient care at both of its locations, including many that members of the general population may not realize.

“I think that’s one of the things that is not completely understood,” Guarente said. “The amount of planning that went into this— queries, data mines, staff assignments, identification of people who had to be fit tested for an N95 respiratory mask, the ones who passed their fit testing for an N95, the supply of N95s drying up, and ,thus, having to change to another N95 brand as a result having to refit and retest the masks to our patient care practitioners.”

Errante agreed, noting that the extraordinary level of detail that the task force needed to go into to make a plan that would ensure the health and safety of the GSDM community.

“We create a lot of aerosol [as dentists], and how is this virus communicated to other people? It’s through aerosol,” Errante said. “So how long does the aerosol stay in the air? How long does it take to fall? When is it safe to go into the patient treatment room? What’s the air exchange of HVAC? I mean, it was incredibly detailed, what we needed to do.”

The detailed planning extended beyond the patient treatment centers into other areas of the building. For example, cleaning protocols had to be examined and modified.

Two custodians from the Boston University Medical Campus (BUMC) are assigned to the building during the day, cleaning high-touch areas including elevator buttons and door handles; at night, 10 custodians clean the entire building. Kiosks with wipes are available throughout the buildings in office and classroom areas for individuals to disinfect their personal spaces.

“We [also] had to go around and calculate the number of people allowed in all the rooms,” said Andy Burke, director of facilities & operations. Burke calculated the capacity using a tape measure and a software that creates a six-foot radius around each chair, couch, table, etc.

The task force also examined how people moved through the building, and in so doing, designated hallways and stairways as one-way or two-way passages. These modified walk-flows allow patients and members of the GSDM community to traverse these passages and stairways safely and avoid any bottlenecks that would make social distancing difficult.

“We had to do a number of walkthroughs, because [a plan] may work on paper, but it isn’t until … you actually walk the new addition to the building and the renovated space in the existing building as a patient, that you actually do realize you need more signage,” said Jon Synnott, director of clinical operations.

Back in Business

On Sunday evening, June 28, 2020, Dean Hutter received approval from the University that GSDM could proceed as planned for its resumption of in-person patient care at both 635 Albany Street and 930 Commonwealth Avenue. This was the last hurdle the school had to clear, as Gov. Charlie Baker had given the green light to all dental procedures, including prophys and cosmetic procedures earlier in the month. While the University’s approval allowed the school to begin seeing patients immediately, GSDM used the remainder of the week to prepare the patient treatment centers and continue training faculty and staff.

The school saw its first patients a week later, on Monday, July 6, 2020. In the first week of operation, GSDM saw approximately 80 patients a day at 635 Albany Street and 50 patients a day at the Dental Health Center at 930 Commonwealth Avenue.

“It’s evolving every day,” Synnott said. “Every day we have a huddle in the morning and say, ‘What did you learn that we can now bring through to today?’ Things are changing all the time. And we have a good routine and we’ve tweaked how we work things”

In Phase 1, he school has been operating at 30 percent capacity, although the exact reduction in capacity varied from department to department, but it will move to Phase 2 and 50 percent capacity, effective August 10, 2020. In Phase 3, the school will move to 75 percent capacity in Phase 3. The final phase will return the school to 100 percent capacity.

The transition between each phase will depend on a number of factors, including, but not limited to continued availability of personal protective equipment (PPE), compliance with social distancing guidelines, and compliance with modified walk-flows throughout the buildings and the Patient Treatment Centers. Additionally, the dean convened a COVID-19 Working Group, which is tasked with evaluating and making recommendations to the dean as to when the school is ready to move to the next phase.

“There are people in this building that have never worked as hard [as they have] over these past 100 days, because of the circumstances that we were under,” Guarente said. “And the willingness to do that has certainly been to the school’s credit. That’s pretty much what we’re about. When you tell us we can’t do it— that’s when we get up and get it done.”